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WELUPUMP PERMIT SAN JOAouiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE} PERMIT j� I CALL (209) 953-7697 FOR INSPECTIONS �/� EXPIRES 1 YEAR FQROM DATE ISSUED JOB ADDRESS < C.2 5 l (b S 1141 C G FA • l j % CRYMP I mo` 4r,+ t c A -( 4 -I 5 3 3 77 CROSS STREET Se-d� I'1 AP 12te' 14 / PARCEL SI LAND USE tAPUCA,TION # OWNER NAME ]1Y^ VAMLmaiP PHONE G, 41-s2a-7�: OWNER ADDRESS -ms e S - Ali It -C 104. CITYISTATFLP 'of!{ea- .� CONTRACTOR tAl►s-fill5 4rMlijIm PHONE 51?, Z4 CONTRACTOR ADDRESS I( A(6t(S nA• CITY/STATE/ZIP MID $ ('11 Q525 7) SUBCONTRACTOR SUBCONTRACTOR AODREss Cr1Y/STATE0P PHONE LICENSE WC -57 ❑ Co -61 ❑ D-09 ❑ Other NUMBER (a!2&12 7_ EXPIRATION DATE t-(- 3 6' DoMEsnc WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) IJ Arsenic (4393) r T�� INTENDED USE )'DomestiGPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Character tion � V� ❑ Public Water System MAY 4 — d dMwerd from Owner: Water System me Name Contsd Naor Phone Nu�rn / )n� TYPE OF WORK ; New well Ykeplacement well ❑ Well AReration/Modifrcation 0 Other ❑ Monitoring WeN(s) # of weft 0 Soil Boring(s) n of borhga o Geotechnical 0 Out4x-service Wen ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair 0 New Pump ❑ Pump Eff6acement 0 Pump Repair ❑ Raise Well Casing WELL CONaTRUCT114N Drilling Method XMud Rotary �, ❑ Air Rotary ❑ Auger 0 Cable Tool 0 Push Point 0 Other Proposed W44 Depth_ -400 ft Excavation' 1TPI in diameter ❑ Open Bottom `Q Gravel Pack/Gravel Size 4& fc2l in diameter ❑ Conduct9r Caging in diameter I Conductor Casing Depth ft Well Casing Diameter _ in Thiccnese/Gauge/ASTM Schad 160 ❑ Steel A Plastic ❑ Stainless Steel U Other Grout Seal Depth 'i& 0 ft ❑ Neat Cement (94 Ib baW5-10 ga/ water) ❑ Sand Cement sack mixf7 gal water ABeMonite (20% soils) ❑ Other Grout Piacemerd Method l44)tmped 0 Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Metaled By ❑ Driller ump Contractor ❑ Other 0 Consols Pedsatd ODinenslons: Width ft Length ft Thick in ❑ Christy Sox 0 SW" Pipe PUMP 0 Subrnersible0 Turbine 0 Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lues. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. 1IINI Ott .til 24 HO R ADN ' Nt I% i i+. i REQ( IRED t OR PSM,E( MONS - I'L,LASE i—ALL. (1041 953-71-607 DEPARTMENT USE ONLY Application Accepted ByLL Data Grout Inspection By Date 9 SkN� ?SZ�Z Pump Inspection By Soil Boring Inspection By COMMENTS CX 15 f) 1 UR 0 Pc�D v)Ilft Date Date � Area Employee ID# , D l7 O SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T EHD043.06102MMI Pap I ort wen / Pwry Perms